Hussa Jr, Edwin NEW YORK STATE DEPARTMENT OF HEALTH -# 4"(al
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edwin F. Hussa,Jr Male
▪ Date of Death Age If Veteran of U.S. Armed Forces,
•!'{' October 20, 2014 91 War or Dates
° Place of Death Hospital, Institution or
Strs City, Town or Village Queensbury Street Address Westmount Health Facility
.1 Manner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
` Circumstances Investigation
. Medical Certifier Name Title
Roslyn Socolof
r?: Address
'▪.,. estmount Health Facility,Queensbury,NY 12804
▪ Death Certificate Filed District Number Itnr Number
's° ity, Town or Village Town of Queensbury 5657
❑Burial Date Cemetery or Crematory
October 22, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z I 'Removal and/or Held
and/or Address
! Hold
Cl)
O Date Point of
tan I I Transportation Shipment
a by Common Destination
Carrier
I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
s Permit Issued to Registration Number
°°7:% Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
r. Address
407 Bay Road, Queensbury, NY 12804
-76
.,33 Name of Funeral Firm Making Disposition or to Whom
`" Remains are Shipped, If Other than Above
Address
'.
r. Permission is hereby granted to dispose of the human re ains described a ove as indicated.
d..
rf. Date Issued1OI�: �y Registrar of Vital Statistics CL. Q (Z`�,
"'7 (signature)
p;. District Number 5657 Place Town of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition (o,zyJi4 Place of Disposition i at.) 6rw-4r--
W` (address)
N
t (section) (lot number) (grave number)
GName of Sexton or Person in Charge of Premises iii,t'f &Ao r
Z (phase print)
W Signature / - ,4, Title 0 "1 4
(over)
DOH-1555(02/2004)